A significant reduction in paediatric post-tonsillectomy vomiting through audit

Factors Associated With Postadenotonsillectomy Unexpected Admissions in Children

BACKGROUND

Postadenotonsillectomy unexpected admission remains an important challenge. Unexpected admissions can be quite frightening, increase health care burden, and cause unnecessary suffering in children and families. Identifying factors associated with postadenotonsillectomy unexpected admissions using a pragmatic approach could lead to a shift in the assessment and management of children presenting for adenotonsillectomy.

METHODS

Institutional review board (IRB) approval, consent, and assent were obtained for this single-center, prospective, observational study done in children aged 0-17 years undergoing tonsillectomy. Data were collected from direct observation, electronic medical record, and phone calls using Research Electronic Data Capture (REDCap) database. Incidence, causes, and factors associated with 3-week and 3-day postadenotonsillectomy unexpected admissions were analyzed.

RESULTS

The study included 2375 children. Clinical intraoperative adverse events were reported in 6.2%. Three-week and 3-day unexpected admissions occurred in 7.9% and 5.9%, respectively, with bleeding being the commonest reason for both. On multivariable analysis, for 3-week unexpected admissions, the odds ratio was 2.3 (95% confidence interval, 1.45-1.69) with using preoperative medications, 1.4 (1.02-1.97) with home medications for comorbidities, 0.56 (0.34-0.90) with using intraoperative acetaminophen, and 0.60 (0.36-0.94) with otolaryngologic preoperative comorbidity versus otherwise. For 3-day unexpected admissions, the odds ratio was 1.10 (1.05-1.16) with 1 U increase in total comorbidities, 1.70 (1.03-2.81) with the presence of recent upper respiratory infection, and 1.83 (1.16-2.90) with intravenous versus inhalational anesthesia induction.

CONCLUSIONS

Overall, our study shows the factors that contribute to unexpected admissions postadenotonsillectomy. Identification of both modifiable and nonmodifiable factors associated with unexpected admissions after adenotonsillectomy will enable appropriate risk mitigation.

Dexamethasone and post-adenotonsillectomy pain in children: Double-blind, randomized controlled trial

OBJECTIVE

To assess the impact of intraoperative intravenous dexamethasone on the reduction of postoperative morbidity in children undergoing adenotonsillectomy.

METHODS

A double blind randomized controlled trial conducted among children undergoing adenotonsillectomy at a tertiary hospital in Korea from November 2018 to June 2019. Children were randomly assigned to receive dexamethasone (0.5 mg/kg, maximum dose 24 mg) or placebo intravenously after induction of anesthesia. The primary endpoint was the reduction of postoperative pain and postoperative nausea and vomiting (PONV); secondary endpoints were adverse effects like postoperative hemorrhage.

RESULTS

The study included 105 children, and 67 were male. Their mean age was 6.2 ± 2.1 years. There was no significant difference between the groups in terms of demographic data or the operation time. The pain scores of the dexamethasone group were lower than those of the control group, but no significant difference was found (all P > .05). The average pain visual analog scale (VAS) during the study period (day 0-7) was 3.67 ± 1.59 and 4.40 ± 2.01 in the dexamethasone group and control group, respectively (P-value = .107). When we compared early pain VAS (day 0-2) and late pain VAS (day 5-7), the dexamethasone group showed significantly lower early mean VAS compared to the control group (4.55 ± 1.78 vs 5.40 ± 2.05, P-value = .046). The mean VAS for PONV was significantly lower in the dexamethasone group than in the control group (1.89 ± 2.22 vs 3.00 ± 2.37, P value = .044).

CONCLUSION

In children undergoing adenotonsillectomy, dexamethasone decreased the early postoperative pain and PONV without increasing postoperative hemorrhage.

The safety of early administration of oral fluid following general anesthesia in children undergoing tonsillectomy: a prospective randomized controlled trial

Background

The feasibility and safety of administrating a small amount of oral fluid to children in the early recovery period following tonsillectomy under general anesthesia to reduce the thirst and its associated restlessness remain unknown.

Methods

This study was approved by the institutional ethics committee and adhered to the CONSORT guidelines. Pediatric patients undergoing tonsillectomy who met the inclusion and exclusion criteria of our study were randomized into the study and control groups. In the study group, patients were given a small amount of water instantly after recovering from general anesthesia, which included the recovery of the cough and deglutition reflex, and attaining grade V of muscle strength. The control group was given a small amount of water at 4 to 6 h after the operation. The incidence of nausea and vomiting and the degree of thirst relief were measured and compared between the two groups.

Results

Three hundred patients were randomized into each group. There was no significant difference in the incidence of nausea and vomiting at 20 min after drinking water between the two groups (P > 0.05). The thirst score of children over 5 years old in the study group was significantly lower than that of the control group (P < 0.05).

Conclusion

Early administration of a small amount of oral fluid to children following tonsillectomy and recovering from general anesthesia is not only safe but also effective in reducing postoperative thirst.

Trial registration

Current Controlled Trials ChiCTR1800020058, 12-12-2018.

Effect of paracetamol/prednisolone versus paracetamol/ibuprofen on post-operative recovery after adult tonsillectomy

OBJECTIVE

To compare the effect of Paracetamol/Prednisolone versus Paracetamol/Ibuprofen on post-operative recovery after adult tonsillectomy.

BACKGROUND

Various analgesic protocols have been proposed for the control of post-tonsillectomy morbidity with need for better control in adult population for having higher severity of post-operative pain and risk of secondary post-tonsillectomy bleeding.

METHODS

This is a prospective cohort study conducted on 248 patients with age of 12 years or older distributed as two equal groups; the first one receiving Paracetamol/Prednisolone and the second one receiving Paracetamol/Ibuprofen. Both groups were compared at 7 days post-operative regarding pain at rest, tiredness of speech, dietary intake, and decrease in sleep duration. Both groups were compared regarding incidence of nausea and vomiting at 2 days post-operative. The incidence and severity of secondary post-tonsillectomy hemorrhage was compared between the two groups.

RESULTS

Pain at rest (no swallowing - no talking) was less in group I but not reaching statistical significance (p = 0.36). In addition, dietary intake was better in group I but not reaching statistical significance (P = 0.17). However, talking ability was better with statistically significant difference (P = 0.03) in group I. Impairment of sleep was less with group II but not reaching statistical significance (p = 0.31). The incidence of vomiting at second post-operative day was less in group I with statistical significance (p = 0.049). The incidence of secondary post-tonsillectomy bleeding was significantly higher in group II with statistical significance (p = 0.046). The severity of bleeding episodes was also significantly higher in group II (p = 0.045).

CONCLUSION

Both ibuprofen and prednisolone were effective as a part of post-operative medication regimen after adult tonsillectomy. However, prednisolone was superior to ibuprofen regarding improvement of pain at rest, dietary intake, tiredness of speech and post-operative nausea and vomiting. However, ibuprofen had a better impact on sleep. The incidence and severity of secondary post-tonsillectomy hemorrhage were significantly higher with ibuprofen favoring the selection of prednisolone to be combined with paracetamol in the post-operative medication protocol following tonsillectomy.

The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: A randomized double-blind clinical trial

BACKGROUND

Local anesthetic infiltration and corticosteroids had shown effectiveness in reducing post tonsillectomy nausea, vomiting and pain.

OBJECTIVES

To compare the effect of intravenous dexamethasone versus pre-incision infiltration of local anesthesia in pediatric tonsillectomy on postoperative nausea and vomiting (PONV). The secondary objective was postoperative pain.

METHODS

A randomized double-blind clinical trial was conducted at a tertiary care teaching hospital. Children admitted to undergo tonsillectomy aged between 4 and 13 years from January 2015 to August 2015 were enrolled and divided into two groups. Both groups had general anesthesia. Group I received intravenous dexamethasone 0.5 mg/kg (maximum dose 16 mg) with placebo pre-incision infiltration. Group II received pre-incision infiltration a total of 2-4 ml local anesthesia mixture with saline and an equivalent volume of intravenous saline.

RESULTS

Group I consisted of 64 patients while group II had 65 patients. In the PACU, 15.6% of patients in group I experienced vomiting compared to 3.1% in group II (p-value = 0.032). After 24 h, the incidence of PONV was significantly higher in group I compared to group II (26.6% vs. 9.2% respectively, p-value = 0.019). At 48 h postoperatively, PONV was significantly higher in group I (p-value = 0.013). The incidence was similar in both groups after three, four and five postoperative days. Baseline pain and pain during swallowing were significantly different at 6, 12 and 24 h as well as days 1 through 5. Pain upon jaw opening was significantly different at 6, 12 and 24 h between the two groups. Pain while eating soft food was significantly different at 24 h and days 2 through 5. In the PACU, 20.3% of patients in group I received diclofenac compared to 3.1% in group II (p-value = 0.005). From day 1 till day 5, analgesic consumption was significantly higher in group I.

CONCLUSION

Local anesthetic infiltration in addition to NSAIDS and paracetamol could serve as a multimodal analgesia and decrease PONV.

TRIAL REGISTRATION

NCT02355678.

Effect of supplemental oxygen 80 % on post-tonsillectomy nausea and vomiting: a randomized controlled trial

Nausea and vomiting are two of the most common complications of tonsillectomy in children. Administration of supplemental 80 % oxygen during surgery reduces the incidence of postoperative nausea and vomiting. We aimed to test the efficacy of supplemental 80 % oxygen during tonsillectomy on postoperative nausea and vomiting. In a randomized controlled trial in Shahid Mostafa Khomeini Hospital in Tehran, 102 children scheduled for tonsillectomy (± adenoidectomy) under general anesthesia were divided randomly in two groups according to percent of administered oxygen (group 1:30 % oxygen, group 2:80 % oxygen). The incidence of postoperative nausea and vomiting were assessed and compared in 0-2, 2-6 and 6-24 h after surgery. Incidence of post-tonsillectomy nausea and vomiting after 2, 2-6, and 6-24 h was 13.72, 1.96 and 1.96 % for group 1 and 3.92, 0 and 1.96 % in group 2, respectively. We found no statistically significant difference between two groups (P = 0.08) but 80 % oxygen was beneficial for reducing postoperative nausea and vomiting in the first 2 h after surgery in group 2.

Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis

Summary In children undergoing tonsillectomy, dexamethasone is recommended to reduce the risk of postoperative nausea and vomiting while non-steroidal anti-inflammatory drugs (NSAIDs) are used for pain relief. We aimed to determine whether children who receive dexamethasone or dexamethasone with NSAID are more likely to experience haemorrhage post-tonsillectomy. Randomized and non-randomized studies in which children undergoing tonsillectomy received dexamethasone or dexamethasone and NSAID were sought within bibliographic databases and selected tertiary sources. The risk of bias assessment and evaluation of haemorrhage rate data collection and reporting were assessed using the Cochrane Risk of Bias Tool and McHarm tool. Synthesis methods comprised pooled estimate of the effect of dexamethasone on the risk of haemorrhage rate using the Peto odds ratio (OR) method. The pooled estimate for haemorrhage rate in children who received dexamethasone was 6.2%, OR 1.41 (95% confidence interval 0.89-2.25, P=0.15). There was risk of bias and inconsistent data collection and reporting rates of haemorrhage in many of the included studies. Clinical heterogeneity was observed between studies. The pooled analysis did not demonstrate a statistically significant increase in the risk of post-tonsillectomy haemorrhage with dexamethasone with/without NSAID use in children. However, the majority of the included studies were not designed to investigate this endpoint, and thus large studies which are specifically designed to collect data on haemorrhage rate are needed.

Post-operative nausea and vomiting following paediatric day-case tonsillectomy: audit of the Epsom protocol

OBJECTIVE

To audit a protocol for elective, day-case, paediatric ENT surgery, previously reported as enabling an overall post-operative nausea and vomiting rate of 2 per cent and a discharge rate of 100 per cent on the day of surgery.

METHOD

The audit included 91 children (45 boys and 46 girls) aged three to 14 years. Forty-seven children underwent tonsillectomy, 36 adenotonsillectomy and eight tonsillectomy with postnasal space examination; indications included recurrent tonsillitis, tonsillitis and nasal block, upper airway obstruction, and a combination of upper airway obstruction and recurrent tonsillitis.

RESULTS

No post-operative nausea or vomiting was recorded in any of the children on the day of surgery, and no discharges were delayed. The reactionary haemorrhage rate was 1 per cent and the secondary haemorrhage rate 3.3 per cent.

CONCLUSION

These findings have implications for the safe same-day discharge of children following tonsillectomy.